Most diseases give you time. Cholera does not.
A healthy adult can wake up well, start passing watery stool by afternoon, and be in life-threatening dehydration before the day ends. The World Health Organization puts it plainly: cholera can be fatal within hours if untreated.
Nigeria has recorded more than 65,000 suspected cholera cases in 2026, spread across 35 states and roughly 195 local government areas — a national picture, not a corner of the country. Weekly cases have come down from the peak earlier in the season, and a smaller share of cases are ending in death than at this time last year. But the outbreak is not over, and the timing matters: we are still in the rainy season, when floodwater mixes with sewage, contaminates wells and boreholes, and overwhelms drainage. NCDC has warned repeatedly across successive rainy seasons that flooding washes contamination into the water people drink.
Here is the part that decides who lives: the treatment that works most of the time costs a couple of hundred naira and is sold in every pharmacy in Nigeria. And a great many families either don’t reach for it, or mix it wrong.
What cholera actually is
Cholera is an infection of the gut caused by a bacterium — Vibrio cholerae — that you swallow in food or water contaminated with it. Not from air, not from touching someone. Through what goes into your mouth.
Symptoms can start as early as 12 hours after infection, or take up to 5 days.
Then there is a detail that explains why cholera spreads through a community so efficiently:
Most people infected with cholera never develop symptoms at all — but they can shed the bacteria in their stool for up to 10 days.
Someone who feels perfectly fine can be contaminating the water everyone drinks. This is why cholera is a community problem and not only a personal one, and why “but nobody here is sick” is not reassurance.
Of those who do fall ill, most have mild or moderate diarrhoea. A minority develop the severe form: relentless watery stool and dehydration that can kill.
Why it kills — it isn’t the infection, it’s the water loss
This is the thing worth understanding, because it changes what you do.
Cholera does not poison your organs. It makes your gut pour out fluid. The bacterium’s toxin forces the lining of the intestine to dump water and salts into the bowel faster than you can drink. Death in cholera is death from dehydration — losing so much fluid that blood pressure collapses and the kidneys and heart cannot continue.
That has a clear consequence: if you can replace fluid and salts as fast as the body is losing them, most people survive. In properly run treatment centres, WHO says case fatality should stay below 1%.
The medicine is fluid. Not an antibiotic. Fluid.
ORS: the sachet, and how to mix it properly
Oral Rehydration Salts (ORS) is a pre-measured powder of glucose and salts. The glucose is not there for energy — it is there because glucose is what drags sodium, and therefore water, across the gut wall and back into the body. That is the whole trick, and it is why ORS works where plain water does not.
The formula WHO and UNICEF recommend has been the low-osmolarity version since 2003, when they reduced its concentration from 311 to 245 mOsm/L to make it gentler and more effective.
First, the thing most people get wrong about ORS
ORS does not stop the diarrhoea. It is not supposed to.
This matters more than any other sentence in this article. Research among Nigerian mothers found that between a third and four-fifths of them expected ORT to stop the diarrhoea — and when it didn’t, many concluded it wasn’t working and stopped giving it.
That misunderstanding is lethal, because in cholera it is not the diarrhoea that kills. It is the dehydration. ORS is not a cure for the infection; it is the thing keeping the person alive while the diarrhoea runs its course.
So: the stool may stay watery for a while yet. Keep giving ORS anyway. You are not failing — you are doing exactly the thing that works.
How to use a sachet:
- Wash your hands.
- Empty one full sachet into exactly 1 litre of clean drinking water — boiled and cooled, sachet water, or safe treated water.
- Stir until completely dissolved.
- Sip small amounts frequently, continuously. Not one big gulp.
- Keep giving it after every watery stool.
- Throw away anything unused after 24 hours and mix fresh.
Never mix a sachet into less than a litre to “make it stronger.” Concentrated ORS pulls water into the bowel and makes the diarrhoea worse.
If you cannot get a sachet — the salt-sugar solution, measured properly
A sachet is always better. But if there is genuinely none, the WHO and UNICEF salt-sugar solution is:
1 litre of clean, boiled-and-cooled water + 6 level teaspoons of sugar + ½ level teaspoon of salt
How to measure 1 litre without a measuring jug: use two 50cl sachets or bottles of pure or bottled water. That is exactly 1 litre, and the volume is printed on the pack, so you can check it yourself.
Read the salt measurement again: half a level teaspoon. Per litre.
There is a version circulating in Nigeria and online that says one full teaspoon of salt. Do not use it. The half-teaspoon formula is deliberately more dilute precisely because it is safer, and it loses almost nothing in effectiveness. In a child who is already dehydrated, too much salt does real harm.
If you are ever unsure, err on the side of too weak — never too salty. A slightly dilute solution still helps. A salty one hurts.
If it tastes saltier than tears, throw it away and mix it again.
The two mistakes that turn a survivable illness into a death
Mistake 1: reaching for antibiotics first.
This is the one I see most as a pharmacist, and it is the reason this article exists. WHO is explicit: giving antibiotics to prevent cholera is not recommended — it has no proven effect on the spread of cholera, and it drives antibiotic resistance.
Antibiotics do have a place in cholera — but that place is inside a hospital, for severely dehydrated patients, alongside intravenous fluids. They are not a substitute for rehydration, they are not a preventive measure for the household, and buying a course over the counter because a neighbour has diarrhoea helps no one and harms everyone eventually.
Mistake 2: using soft drinks, fruit juice or energy drinks instead of ORS.
It feels reasonable — sugar and liquid, surely that helps. It does the opposite. These drinks are far too concentrated in sugar. That concentration pulls water out of the body and into the bowel, which means more watery stool and faster dehydration. Sweet drinks are not rehydration. They are the wrong tool at the worst moment.
Plain water alone is also not enough on its own — it replaces the water but not the salts that are being lost.
For children: add zinc
For a child with diarrhoea, WHO recommends zinc alongside ORS:
- 20 mg per day for 10–14 days for children
- 10 mg per day for infants under 6 months
Zinc shortens the episode and reduces the chance of another one in the following months. Ask for it at the pharmacy by name — it is cheap, and it is routinely forgotten.
And keep feeding. Continue breastfeeding an infant throughout. A child with diarrhoea who stops eating recovers more slowly.
When to stop rehydrating at home and go to hospital — today
ORS handles mild and moderate illness. Severe dehydration needs a drip, and that means a facility. Go now if you see:
- Sunken eyes, or a sunken soft spot on a baby’s head
- No urine for many hours, or very dark, scanty urine
- Skin that stays pinched when you pinch and release it
- Too weak to drink, drowsy, confused, or unable to stay awake
- Repeated vomiting so nothing can be kept down
- A stool that looks like cloudy rice water, pouring rather than passing
- Any of the above in a child under 5, an older adult, or a pregnant woman
Take the ORS with you and keep giving it on the way. Rehydration on the journey is not wasted time — it is the treatment starting early.
Stopping it before it starts
Cholera is a water-and-sanitation disease. What actually protects a household:
- Drink only water you know is safe — boiled and cooled, properly treated, or sealed sachet/bottled water. During floods, treat every source as suspect, including a borehole you have always trusted.
- Store treated water in a covered container and pour it out — don’t dip cups or hands into it.
- Wash hands with soap after the toilet and before cooking or eating. Soap, not just water.
- Eat food hot and cooked. Be careful with raw salads, cut fruit and ice sold on the street during an outbreak — ice is made from water.
- Don’t let the toilet drain near the water source, and report broken sewage or burst pipes rather than living with them.
There is also a vaccine. Oral cholera vaccines — Dukoral, Euvichol-Plus and Euvichol-S — exist and work. Two doses give full adult protection, though because of a global shortage, since October 2022 campaigns have been using single doses, which still give good short-term protection. Euvichol-Plus and Euvichol-S can be given from age one, and are safe in pregnancy. These are deployed through outbreak campaigns rather than sitting on pharmacy shelves — so if a campaign reaches your area, take it.
The bigger picture
Cholera belongs to the same family of lessons this site keeps coming back to: that in Nigeria, illness is too often guessed at, and the guess is too often a drug. We’ve written about why “malaria and typhoid” is so often the wrong answer, about Lassa fever hiding behind malaria’s symptoms, about diphtheria returning through a vaccination gap, and about checking that the medicine you buy is genuine.
Cholera adds the sharpest version of it. Here the correct answer is not a clever drug at all. It is clean water, and salt and sugar in the right proportion, given fast enough. Globally, cholera still causes an estimated 1.3 to 4 million cases and tens of thousands of deaths a year — a disease we have understood for over a century, still killing people for want of a sachet.
The pocket check
Watery diarrhoea → start ORS immediately, one sachet per litre, small sips, after every stool. Sunken eyes, no urine, too weak to drink, or rice-water stool → hospital today, still drinking ORS on the way. No sachet? Two 50cl sachets of pure water (= 1 litre) + 6 level teaspoons sugar + ½ level teaspoon salt. And not an antibiotic bought over the counter — fluid.
This article is for information only and is not a diagnosis or a treatment plan. Severe watery diarrhoea with dehydration is a medical emergency — go to a hospital immediately.
Sources: World Health Organization cholera fact sheet (5 December 2024); WHO and UNICEF oral rehydration therapy guidance, including the low-osmolarity ORS formulation and the home salt-sugar solution; WHO zinc recommendations for childhood diarrhoea; Nigeria Centre for Disease Control and Prevention (NCDC) Director-General statements on 2026 cholera figures and the NCDC nationwide flood-season alert on cholera, yellow fever and dengue.